KAHIMA Scholarship Application Demographic InformationName * Name Name Name Credential Email * Phone Address City State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip Are you a member of AHIMA? * Yes No AHIMA ID # * Gender Male FemaleMarital Status Single Married Separated WidowedWill you be employed while attending school? Yes NoList your employer and job title. List your employer and job title. List your employer and job title. List your employer and job title. Personal Letters of ReferenceUpload two personal online letters of reference (other than family, clergy, or program director). Candidates are encouraged to obtain one of the two personal letters from a clinical instructor. Reference Letter #1 * Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Reference Letter #2 * Drop a file here or click to upload Choose FileMaximum file size: 268.44MBFamilyName of Parent, Guardian, or Spouse Name of Parent, Guardian, or Spouse Name of Parent, Guardian, or Spouse Name of Parent, Guardian, or Spouse Phone of Parent, Guardian, or Spouse Address of Parent, Guardian, or Spouse City of Parent, Guardian, or Spouse State of Parent, Guardian, or Spouse AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Zip of Parent, Guardian, or Spouse If you are being supported by a parent, give number of other dependent children. Financial Aid What is the amount and source of any financial aid that you currently receive? Education High School* Include school name, location, date of graduation Post-High School Education* Include school name, location, date of graduation Name of education program (Enrolled or have been accepted) Expected Graduation Date * Upload Transcript * Drop a file here or click to upload Choose FileMaximum file size: 268.44MB Please describe your professional or business experience. Please describe professional association activities. Please describe your reason(s) for choosing HIM as a career and an outline of your career goals. Please describe a contribution that you can make to the profession. Please describe your reason for applying for the scholarship fund. AgreementsI agree to maintain student membership in AHIMA. * I agree to maintain student membership in AHIMA.Should I not complete the education program, I agree to reimburse KAHIMA the amount of the scholarship. * Should I not complete the education program, I agree to reimburse KAHIMA the amount of the scholarship. If you are human, leave this field blank. SubmitΔ
